LUGPA Policy Alert – Severe Reimbursement Reductions Threaten Patient Access to Advanced Cancer Care
December 2025
At-a-Glance Essentials
What’s Changing:
Beginning January 1, 2026, independent radiation oncology practices, including those embedded in large urology groups, face major Medicare payment cuts driven by new bundled CPT codes, loss of global IGRT reimbursement, RVU shifts tied to hospital cost data, and additional conversion factor reductions. Commercial policies, including EviCore’s 2026 guidelines, impose further restrictions on advanced radiation techniques.
Why It Matters to Urology:
These changes disproportionately affect freestanding and physician-owned centers that deliver radiation therapy for prostate, bladder, and kidney cancers. Significant revenue losses, restrictive medical necessity requirements, and increased administrative burden threaten the viability of integrated radiation programs and risk pushing patients into higher-cost hospital settings.
Action Points:
- Model the financial impact of the 2026 cuts on radiation service lines.
- Begin early payer engagement to renegotiate 2026 contract terms and mitigate anticipated reductions.
- Develop standardized clinical-justification templates to support higher-complexity coding and reduce denials.
- Review and strengthen IGRT documentation to ensure compliance and limit recoupment risk.
- Prepare for higher peer-to-peer volume by designating clinical leads and creating escalation pathways.
- Assess service-line sustainability under reduced reimbursement and establish contingency plans for affected modalities.
Key Dates:
Jan 1, 2026: New CPT bundle for delivery + IGRT takes effect; IGRT global billing ends; EviCore policy changes go live.
2025–2026: Critical period for payer engagement, contract adjustments, and operational planning.
Introduction
Beginning January 1, 2026, independent radiation oncology practices, including those integrated within large urology group practices, face a perfect storm of Medicare reimbursement cuts and increasingly restrictive commercial payer guidelines.
These cuts disproportionately impact freestanding and physician-owned centers, placing independent urology groups that provide prostate, bladder, and kidney cancer radiation therapy services at severe financial and operational risk. Without immediate advocacy and payer engagement, LUGPA fears that many centers may have to limit services, refer patients to hospital systems, or close entirely, accelerating consolidation and reducing community-based access to cancer care.
Key 2026 Changes Driving the Crisis
New AMA CPT® Codes and Bundling of Radiation Delivery + IGRT
New RVU Valuations and Loss of Global IGRT Billing in Freestanding Centers
- Practice expense RVUs are now derived from hospital-reported costs, not freestanding cost data
- Beginning January 1, 2026, global billing of IGRT by freestanding centers ends; only the professional component (77387-26) is payable in the non-facility setting
- Net effect: 20–30% revenue loss for common prostate, breast, and lung cancer courses
Conversion Factor + “Efficiency” Adjustment Cuts
- Despite a nominal CF increase, a new –2.5% efficiency adjustment and ongoing budget neutrality reductions will continue to erode payment amounts
- Radiation oncology faces continuing annual volatility, absent permanent site-neutral reform
2026 CMS Radiation Oncology Reimbursement Changes – At a Glance
- Effective Jan 1: IMRT codes 77385, 77386 deleted
- Replaced by bundled complexity-based radiation therapy treatment codes 77407 (intermediate) and 77412 (complex)
- No automatically higher reimbursement for IMRT/VMAT
- Prostate cancer impact: LUGPA believes most cases will be reported with code 77407, creating a 10–20% cut compared to 2025 IMRT payments unless additional complexity is justified
- Combined with the new efficiency adjustment → significant revenue losses and heightened risk of practice closures
EviCore (Cigna) 2026 Radiation Oncology Guidelines
- Effective January 1, 2026, EviCore will adopt the most restrictive utilization management policy we have seen to date
- Forces downgrades from IMRT to 3D-CRT even when ASTRO/NCCN guidelines support advanced techniques
- Severely restricts IGRT, SBRT, hypofractionation, and re-irradiation
- Omits key clinical evidence (e.g., Deep Inspiration Breath Hold (DIBH)/surface guidance for left-sided breast; perioperative gastric data; immunotherapy + RT sequencing)
- Expected to produce widespread denials and a surge in peer-to-peer requirements
Why This Matters to Urology Group Practices
- Many LUGPA groups own or have JV radiation oncology services critical for prostate cancer care
- Loss of freestanding radiation capability forces referrals to hospital systems—undermining comprehensive in-house cancer care and group sustainability
- Rural and community access to advanced techniques (SBRT, SpaceOAR, DIBH) will decline
- Administrative burden from appeals will divert physician and staff time from patient care
Bottom Line
The 2026 policy changes represent the most significant reimbursement threat to independent radiation oncology in more than a decade. For large urology group practices that have invested heavily in providing high-quality, convenient, community-based cancer care, the financial and clinical implications are existential.
LUGPA members must act now—through federal and commercial payer advocacy, contract review, and proactive negotiations—to preserve access to advanced radiation therapy in an independent setting.
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